Healthcare Provider Details

I. General information

NPI: 1528485695
Provider Name (Legal Business Name): IRIS JO-SHI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IRIS JO DO

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 HAMAKER CT STE 600
FAIRFAX VA
22031-2241
US

IV. Provider business mailing address

3023 HAMAKER CT STE 600
FAIRFAX VA
22031-2241
US

V. Phone/Fax

Practice location:
  • Phone: 703-876-2788
  • Fax: 703-839-8764
Mailing address:
  • Phone: 703-876-2788
  • Fax: 703-839-8764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number0102206212
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: